Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDR06s !I U /l e �` f2,11IC /\)� CITY IP / f �fT z� m <br /> CR(`SS STREFrTl�y, (/r41 k APN �rrv7✓� `�j�yO�Z PARCEL SIZE F- L 1 LAND/USE APPLILICCAATIO�N,i## (/ m <br /> OIYNER NA/M/E/ Y��1)1 1<&rt�� 7 er re 1(J /� to <br /> OWNER ADDRESS l! Y�� ` e C <br /> / 1 CITY/STAT �7`IP �IL � uZX <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE I, C-57 ,I C-61 l D-09 ; Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section <br /> INTENDED USE 11 Domestic/Private Irrigation/Agricultural N Industrial Water Quality Monitoring U Soil Sampling/Characterization <br /> 1 I Public Water System <br /> If different from Owner: —Water System Name ContacI Name or Phone Number <br /> TYPE OF WORK Fi New Well 1 Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) _ #of wells D Soil Boring(s) --- #of borings Geotechnical #of borings <br /> ` Out-Of-Service Well L Out-Of-Service Well Renewal I I Cross-Connection Repair <br /> P New Pum Pump Replacement ❑ Pump Repair I I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method a Mud Rotary Air Rotary I! Auger 1 Cable Tool CI Push Point 11 Other <br /> Proposed Well Depth ft Excavation in diameter 7 Open Bottom I 1 Gravel Pack/Gravel Size in diameter <br /> 1.1 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched J Steel L! Plastic C Stainless Steel D Other_ <br /> Grout Seal Depth ft LF Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> I Bentonite(20%solids) f I Other <br /> Grout Placement Method :I Pumped =1 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By 17 Driller `. Pump Contractor Ll Other <br /> 'I Concrete Pedestal Dimensions:Width ft Length ft Thick in Ci Christy Box F' Stove Pipe <br /> PUMP I Submersible Turbine I Other HP Pump Set It Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU 24 HOUR ADVANCJY NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED, J - LLQ TiTL - LJHPV DATE <br /> MP FOItl4 — 5�� - <br /> CR&Eli F9riAga <br /> [ VU �' y <br /> FFn: <br /> J uve ora Rniip a j <br /> i <br /> USE ONLYApplication Accepted Byi.,nI,,,,,,,K: PARTMENT <br /> Date I` Area D� Employee l�` L-t A <br /> f-sNe•ctiC., y _,;e 0.,...t .,n n aV rLifNl- el:i 7--rim., <br /> i-/:!i! <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS J�� Y li644i l Ib <br /> — 2 0 t ZS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHD 43-06 WELL/PUMP PERMIT <br /> 4/30/12 <br />